Com o objetivo de estudar o processo de referência de pacientes que procuram um Hospital Universitário, pela primeira vez e analisar algumas características destes pacientes e as inter relações entre a localização do domicílio, a utilização de outros serviços, as dificuldades e facilidades apresentadas pelos pacientes, para procurar o Hospital, foram investigados todos os pacientes que procuraram um Hospital Universitário. O trabalho foi realizado no período de cinco semanas de outubro e novembro de 1983, a saber: de 3 a 7, 17 a 21 e 24 a 27 de outubro e de 7 a 11 e 21 a 25 de novembro. Através de entrevistas foi preenchido um formulário com questões sobre características do paciente tais como: sexo, idade, nível de instrução; ocupação, local de residência, gravidade dos sinais e sintomas que os levaram a procurar o Hospital, motivo da demanda, distância do domicílio ao Hospital, utilização de outros serviços, tipos de encaminhamento. A hipótese diagnóstica foi obtida do prontuário do paciente, após a consulta. Foram estudados 1.601 pacientes, sendo 59,53 por cento do sexo feminino e 40,47 por cento do sexo masculino. A maior concentração de pacientes pertence ao grupo etário de 15 a 24 anos (24,49 por cento ), seguido pelo de 25 a 34 anos (17,86 por cento ). O nível de instrução mostrou-se bastante baixo, uma vez que, 54,63 por cento tinha o primeiro grau incompleto e 30 por cento analfabetos. A ocupação que apareceu com maior freqüência foi as donas de casa (43,94 por cento ), seguida pelos agricultores (15,51 por cento ), trabalhadores dos serviços dos desportos e das diversões (13, 64 por cento ). Como Hospital Regional 46,34 por cento dos pacientes procedem da região de Ribeirão Preto e 37,48 por cento do próprio município, onde está localizado. A procedência de pacientes na zona rural aumenta proporcionalmente, em relação à urbana a medida que se afasta do município de Ribeirão Preto. De maneira geral, os pacientes da zona urbana procuram mais precocemente o Hospital, quando residem mais próximo dele. A maioria dos pacientes que residem próximo e procuram o Hospital é portador de sinais e sintomas considerado leve, aumentando a proporção de sinais e sintomas graves entre os pacientes que residem mais distantes do Hospital. 32,57 por cento dos pacientes portadores de sinais e sintomas leves e 25,12 por cento dos portadores de sinais e sintomas graves não procuraram outro serviço, antes de demandarem ao Hospital e informaram não ter procurado outro serviço, por falta de recursos para pagar assistência médica e não confiar no Centro de Saúde. Dentre os pacientes que procuram outros serviços antes, apenas 54,4 O por cento foram referidos para o Hospital e 87,36 por cento destes não receberam orientação para, após o atendimento no Hospital, retornarem a seu serviço de origem. O fluxo de pacientes ao Hospital diminuiu paulatinamente, no decorrer da semana. As doenças do sistema nervoso e dos órgãos dos sentidos ocupam o primeiro lugar entre as hipóteses diagnósticas dos pacientes que procuram o Hospital, pela primeira vez. Dos 1601 pacientes atendidos, 14,74 por cento não foram registrados, conforme rotina estabelecida pelo Hospital, podendo gerar estatísticas imperfeitas. O estudo do processo de referência ao Hospital mostrou-se importante para o conhecimento das características dos pacientes, das inter relações com os outros serviços e das peculiaridades própria do Hospital, como subsídio para organização da assistência à saúde. / With the objective to study the process of referral of patients who look for a University Hospital for the first time and to analyze some characteristics of these patients and the interrelationships between the location of their homes, the use of other services and the difficulties or the facilitation met by the patient to contact the hospital, all the patients who looked for a University Hospital were investigated. The study was conducted over a period of five weeks from October 3 to 7, 17 to 21 and 24 to 27 and from November 7 to 11 and 21 to 25, 1983. Each patient was interviewed and a form was filled out with answers to questions of the characteristics of the patient such as sex, age, level of education, occupation, place of residence, seriousness of the signs and symptoms that led him to look for the Hospital, reason for the demand, distance of the residence from the Hospital, type of referrals. The diagnostic hypothesis was taken from the patient\'s medical record after his medical visit. A total of 1601 patients were studied; 59.53 per cent were women and 40.43 per cent were males. Most patient were concentrated in the 15 to 24 year age range (24.49 per cent ), followed by the 25 to 34 year age range (17.86 per cent ). The level of education was quite low, since 54.63 per cent had not completed elementary school and 30 per cent were illiterate. The most frequent types of occupation were: housewife (43.94 per cent ), followed by rural workers (15.51 per cent ) and by workers in suports and amusement services (13.64 per cent ). Since this is a Regional Hospital, 46.34 per cent of the patients were from the Ribeirão Preto region and 37.48 per cent from the town itself in which the Hospital is located. The origin of patients from the rural zone increased proportionally in relation to the urban zone with the distance from Ribeirão Preto. In general, the patients from the urban zone look earlier for the Hospital when they live closer to it. Most of the patients living close to the Hospital had signs and symptoms considered mild, with an increase in the proportion of serious signs and symptans anong the patients who live farther away from the Hospital. 32.57 per cent of the patients with mild signs and symptoms and 25.12 per cent of the patients with serious signs and symptoms did not look for any other service before contacting the Hospital and informed that they had not lookes for other services because of lack of money to pay for medical assistance and because they did not trust the health center. Among the patients who had previously looked for other services, 54.40 per cent were referred to the Hospital and 87.36 per cent of these did not receive guidance to return to the original service after being attended at the Hospital. The flow of patients to the Hospital decreased little by little with each passing week. Diseases of the nervous system and of the sensory organs occupied first place among the diagnostic hypotheses for the patients who looked for the Hospital for the first time. Of 1601 patients attended, l4.74 per cent were not registered according to the routine established by the Hospital, a fact that may give rise to imperfet statistics. The study of the process of referral to the Hospital proved to be important in terms of learning about the characteristics of the patients, the interrelationships with the other services and the peculiarities of the Hospital, as an aid in organizing health assistance.

Telefonrådgivning kräver ett kvalificerat handläggande där sjuksköterskan på kort tid ska kunna etablera en god vårdrelation med patienten trots att den visuella kontakten saknas. Förutom kunskaper inom medicin krävs det att telefonsjuksköterskan har en god förmåga till kommunikation och visar respekt och empati för patienten. Efterfrågan på telefonrådgivning ökar och detta ställer krav på specifik kompetens hos sjuksköterskan. Vi har därför valt att beskriva vad som kännetecknar sjuksköterskans arbete med telefonrådgivning för att få kunskap i om hur vi i vår profession kan bli bättre på att ge råd via telefon. Det har gjorts i form av en litteraturstudie med grund i analys av kvalitativa artiklar samt en kvantitativ artikel. Kvalitativa studier kan vara vägledande för det praktiska arbetet och bidrar till att skapa en evidensbaserad omvårdnad. I resultatet framkommer tre huvudteman. Det första är telefonrådgivning ur sjuksköterskans perspektiv, med fyra subteman. Det andra huvudtemat är patientrelaterade faktorer som påverkar telefonrådgivningen med tre subteman. Det sista huvudtemat är organisatoriska faktorer som påverkar telefonrådgivningen med tre subteman. I diskussionen reflekterar vi över hur fortbildningen inom telefonrådgivningen kan utformas. Vidare diskuterar vi hjälpmedel som kan användas av telefonsjuksköterskan och dessutom tar vi upp betydelsen av feedback. / Program: Fristående kurs

Infant health care use has rarely been examined empirically. A growing literature links maternal health and psychosocial variables to broadly defined pediatric health care use. The Common Sense Model of health and illness behaviors (CSM) provides a framework from which to view the role of the maternal psychosocial variables examined (i.e. maternal negative affect, lay consultation and parenting self-efficacy) in infant health care decision-making. Findings for infant health care use are reported specific to referral source (i.e. mother versus physician initiated infant health care). Physician initiated visits were not significantly predicted by the models tested, consistent with the independence of predictor variables from initiation source (i.e. mothers versus physicians). Mother initiated visits were significantly predicted by the model containing the Lay Consultation worry item, which was also the only variable that significantly predicted infant health care use in the model. The main dissertation study finding is the independence of infant health care use decision-making from most of the maternal psychosocial, demographic and enabling variables examined. The finding is positive for the health care system as it suggests that mothers generally do not seek infant health care for their own emotional regulation and/or reassurance in their parenting competency. The contextual component of the CSM, as measured by lay consultation, received support from the findings, suggesting that mothers' perceived worry of her lay consults results in greater infant health care use. Implications for mothers and infants include community psychoeducation programs and home visiting programs focusing on infant health and development psychoeducation.

The purpose of this study was to examine factors that relate to the delivery of mental health services by school psychologists using a national database. The relationship between school psychologists' demographic, preparation, and professional context factors (e.g., gender, ethnicity, educational level, percentage of minority students served, years of experience, and students to school psychologist ratio), and the types of mental health services delivered, amount of time invested in such services, and the desirability of school psychologists to provide or not to provide mental health services was addressed. In addition, the percentages of school psychologists who deliver mental health services and the amount of time they spend in broadly defined mental health service types was addressed. Results of the analyses suggest that students to school psychologist ratio, gender, and percentage of minority students served significantly predict the types of mental health services delivered by school psychologists. In addition, students to school psychologist ratio was related to the amount of time school psychologists spend providing consultation, assessment, and intervention services related to mental health. There was a statistical significant difference in the desire to provide or not to provide more mental health services for male and female psychologists and psychologists with different educational levels. Inaddition, school psychologists' years of experience were related to their desire to provide or not to provide more mental health services. On average, school psychologists in this sample provided seven types of mental health services weekly and provided approximately 29 hours of service related to mental health per week. These results provide initial information as to what factors support school psychologists providing mental health services in schools. This information is important for training programs and legislation to ensure that students are receiving optimal mental health services in schools.

Every attempt by the NSW State Government to site waste treatment and disposal facilities has been met by opposition from local communities. Increasing interest is being shown in community consultation and public participation in the decision-making processes concerning the siting of waste management technologies. This thesis examines the rationale behind, and potential of, community consultation through an examination of two case studies. The thesis concludes that the reasons and remedies for local opposition typically given by experts and regulatory authorities are flawed. The engineering concerns which have dominated approaches to choosing and siting waste management technologies are of little consequence to the way in which communities judge whether the facilities pose an acceptable societal risk. The issues of concern to communities include the legitimacy of the decision-making process, the relative fairness of the decision to site, and whether the institutions responsible for managing and operating the technologies are trustworthy. If waste management technologies rely on local acceptability for their siting, the approach taken to resolve the waste problem must include societal as well as engineering concerns in the design of courses of action to manage the risk. / Doctor of Philosophy (PhD)

<p>Telefonrådgivning via en sjuksköterska har funnits ända sedan 1930-talet men det är först de senaste åren som denna kompetens har erkänts som en egen specialitet. Inom vården sker allt fler möten mellan vårdgivare och vårdsökande via telefonen vilket leder till att allt högre krav ställs på sjuksköterskans yrkeskunnighet. Studiens syfte var att beskriva vad sjuksköterskor upplever vid telefonrådgivning till personer med psykiska problem. Metoden som använts i denna litteraturstudie var kvalitativ innehållsanalys med manifest och latent ansats. Resultatet baseras på 10 vetenskapliga artiklar där fyra kategorier framkom: trygghet, utsatthet, ett känsligt öra samt meningsfullhet. I resultatet framkom att kunskap och klinisk erfarenhet är faktorer som har stor betydelse för yrkesrollen inom telefonrådgivning. Som rådgivningssjuksköterska inom psykiatrisk vård upplevde många en hög stressnivå vad gäller den komplexa yrkesrollen. Att inte se patienten med sina egna ögon upplevdes som att delvis arbeta i blindo. Detta ledde till att rådgivningssjuksköterskorna lyssnade aktivt för att försöka förstå vad som uttrycktes mellan raderna i samtalet med den vårdsökande. Ett etiskt dilemma som rådgivningssjuksköterskor beskriver är upplevelse av svårigheter att hantera andrahandsinformation vid telefonrådgivning. Dessa svårigheter uppkommer då rådgivningssjuksköterskan ej har möjlighet att tala direkt till den person som telefonråden gäller. För övrigt gavs uttryck för att arbetet som rådgivningssjuksköterska är stimulerande och utmanande</p>

Telefonrådgivning via en sjuksköterska har funnits ända sedan 1930-talet men det är först de senaste åren som denna kompetens har erkänts som en egen specialitet. Inom vården sker allt fler möten mellan vårdgivare och vårdsökande via telefonen vilket leder till att allt högre krav ställs på sjuksköterskans yrkeskunnighet. Studiens syfte var att beskriva vad sjuksköterskor upplever vid telefonrådgivning till personer med psykiska problem. Metoden som använts i denna litteraturstudie var kvalitativ innehållsanalys med manifest och latent ansats. Resultatet baseras på 10 vetenskapliga artiklar där fyra kategorier framkom: trygghet, utsatthet, ett känsligt öra samt meningsfullhet. I resultatet framkom att kunskap och klinisk erfarenhet är faktorer som har stor betydelse för yrkesrollen inom telefonrådgivning. Som rådgivningssjuksköterska inom psykiatrisk vård upplevde många en hög stressnivå vad gäller den komplexa yrkesrollen. Att inte se patienten med sina egna ögon upplevdes som att delvis arbeta i blindo. Detta ledde till att rådgivningssjuksköterskorna lyssnade aktivt för att försöka förstå vad som uttrycktes mellan raderna i samtalet med den vårdsökande. Ett etiskt dilemma som rådgivningssjuksköterskor beskriver är upplevelse av svårigheter att hantera andrahandsinformation vid telefonrådgivning. Dessa svårigheter uppkommer då rådgivningssjuksköterskan ej har möjlighet att tala direkt till den person som telefonråden gäller. För övrigt gavs uttryck för att arbetet som rådgivningssjuksköterska är stimulerande och utmanande

This dissertation uses population-based administrative healthcare data to evaluate the outcomes, processes-of-care and practice variation associated with preoperative medical consultation in Ontario, Canada. First, a multicentre cross-sectional study was conducted to develop a novel algorithm for identifying preoperative medical consultations using administrative data. The optimal claims-based algorithm was a physician service claim for a consultation by a cardiologist, general internist, endocrinologist, geriatrician, or nephrologist within 120 days before the index surgery. This algorithm had a sensitivity of 90% (95% confidence interval [CI], 86 to 93) and specificity of 92% (95% CI, 88 to 95). Second, we conducted a population-based cohort study to evaluate the association of preoperative medical consultation with outcomes and processes-of-care. After adjustment for measured confounders using propensity-score methods, consultation was associated with increased preoperative testing, preoperative pharmacological interventions, 30-day mortality [relative risk (RR) 1.16; 95% CI, 1.07 to 1.25], 1-year mortality (RR 1.08; 95% CI, 1.04 to 1.12), and mean hospital stay (difference 0.67 days; 95% CI, 0.59 to 0.76). These findings were stable across subgroups, as well as sensitivity analyses that tested for unmeasured confounding. Third, temporal trends and practice variation in consultation were evaluated within the population-based cohort. The proportion of patients undergoing consultation remained relatively stable over the study period, at approximately 39%. Although patient-level and surgery-level factors did predict consultation use, they explained only 6.8% of variation in consultation rates. By comparison, inter-hospital differences in rates were substantial (range, 1.9% to 86.8%), were not explained by surgical volume or teaching status, and persisted after adjustment for patient-level and surgery-level factors. Overall, this dissertation highlights the need for research to identify interventions for safely decreasing perioperative risk, define mechanisms by which consultation influences outcomes, examine factors that influence practice variation in medical consultation, and identify patients who benefit most from preoperative medical consultation.

The importance and benefits of involving community members in health policy making-­-from the first step of needs assessment through to actual policy development--are increasingly being recognized. This thesis describes the evaluation of a community consultation process which was part of a needs assessment conducted by Saskatoon District Health, in Saskatchewan, Canada. In September 1995, a Children and Youth Working Group was formed, made up of volunteers representing service providers, users, and families. Their mandate was to develop and priorize recommendations on ways to improve the health status of children and youth in the District, which has a total population of approximately 300,000. In addition to a comprehensive epidemiological assessment, the Working Group engaged in a community consultation process which solicited input from the general community, with a specific emphasis on key groups such as youth, Aboriginal, immigrant/refugees, and service providers in health, education, social services, and justice. In this process, information on perceived needs of children and youth was collected through 20 focus groups (n=213) and a questionnaire (n=1,985). Based on a synthesis of the quantitative and qualitative data, the Working Group drafted a set of recommendations, which were then discussed at a community meeting for input and feedback. <p> This research evaluates the effectiveness of the consultation process in facilitating community participation using three sources of data: the entire consultation process was observed (from January 1996 until February 1997), including the focus groups, Working Group meetings, and the final community meeting; interviews (2) were held with the Working Group (n=9), with selected individuals who had participated in the consultation (n=7), and with non-participants (n=2); and documentation produced by the Working Group (i.e., minutes, notes, background material) was reviewed. These data were analyzed thematically according to criteria established jointly by the representatives of the member groups of the Population Health Project (Working Group, Coordinating Group, Research Advisory Group) and the researcher. The effectiveness was gauged by comparing the findings with the criteria and with the components of meaningful community consultation as defined by the Working Group (appropriateness, timeliness, completeness, accuracy, representativeness, relevance). The themes which emerged from the analysis deal with the participants' feelings about their participation or non­participation, the success of the consultation process, the nature of the data collected; by-­products of the process, and the consultation's influence on the outcome of the needs assessment. The results of this analysis are presented and conclusions drawn regarding factors that contribute to or impede effective public participation in health needs assessment.

School psychologists have increased their practice of consultation within the schools due to mandates by the National Association of School Psychologists (NASP) and positive outcomes associated with the service. Previous research has examined how training directors at school psychology graduate programs viewed consultation training. The current study investigated how school psychologists view their training in consultation and how they view the practice of consultation in school systems. A random sample of 510 school psychologists from across the country was sent a survey to obtain their perspectives on consultation. A 46% return rate was achieved. The respondents were divided into two groups based on the practitioner’s years of experience (i.e., more than 10 years experience and less than 10 years experience) in order to make comparisons based on when the school psychologists received their training. Results indicated that recent graduates reported more comprehensive training in consultation, a heavier emphasis on collaborative and problem-solving consultation and significantly higher levels of satisfaction with consultation training and practice. However, recent graduates did not perceive their skills with consultation to be higher than school psychologists with less training, but more experience.